Effective Dates: 8/05/2025 - Present

Identification Number:
QR 04440 TN 16
Intended Audience:OQR
Originating Office:OARO Office of Quality Review
Title:Federal Quality Review of Disability Det
Type:POMS Full Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM

Part QR – Quality Review

Chapter 044 – Quality Appraisal

Subchapter 40 – Federal Quality Review of Disability Det

Transmittal No. 16, 08/05/2025

Originating Component

OQR

Effective Date

Upon Receipt

Background

Quality Review is moving materials from Part GN Chapter 044 to the appropriate Part QR and new Chapter 044. This new section is part of a conversion series of Quality Review GN sections to the new QR Chapter 044.

Summary of Changes

QR 04440.130 Medical Review in the Office of Quality Review (OQR)

We copied GN 04440.130 to establish QR 04440.130

 

QR 04440.150 Processing Correct Or Corrected Disability Cases

We copied GN 04440.150 to establish QR 04440.150

QR 04440.201 Deficiency Citation and Support

We copied GN 04440.201 to establish QR 04440.201

QR 04440.202 Group I Decisional Deficiencies

We copied GN 04440.202 to establish QR 04440.202

QR 04440.203 Group I Documentation Deficiencies

We copied GN 04440.203 to establish QR 04440.203

QR 04440.204 Group II Deficiencies

We copied GN 04440.204 to establish QR 04440.204

QR 04440.130 Medical Review in Quality Review (QR)

 

A. Medical review in the federal review component

The review component performs quality reviews of all sampled cases to ensure policy compliance and to determine whether a medical contractor (MC) or psychological contractor (PC) review is required or is discretionary.

B. MC and PC review criteria

Based on the instructions below, the reviewer determines whether a case requires review by, and input from, an MC and/or PC.

1. Cases requiring medical review

The reviewer is required to obtain a review by an MC or PC for:

  1. a. 

    any case with a group I medical deficiency, unless the file contains NO medical evidence or the case is a continuing disability review (CDR) case without any current medical evidence;

  2. b. 

    any case or workload required per instructions from the Associate Commissioner of Quality Review, or designee;

  3. c. 

    any case where QR assumes jurisdiction. (See QR 04440.244 Assuming Jurisdiction.)

2. Discretionary medical review

If review by an MC or PC is not required, reviewers may use their judgment in deciding whether to seek medical consultation.

  1. a. 

    The reviewer may obtain review by an MC or PC in cases with questions or issues regarding:

    • •

      impairment severity

    • •

      inconsistencies in the evidence

    • •

      the claimant’s ability to sustain a normal workday or workweek

    • •

      medical improvement

    • •

      duration, onset, end or cessation dates, or closed periods

    • •

      whether the medical evidence in file is sufficient

    • •

      symptom evaluation and limitations to function

    • •

      psychiatric review technique (PRT), residual functional capacity (RFC) or mental residual functional capacity (MRFC) assessment(s)

  2. b. 

    The reviewer generally does not need review by, or input from, an MC or PC for cases with:

    1. 1. 

      Group I non-medical deficiencies such as:

      • •

        clear evidence that the individual is engaging in substantial gainful activity (SGA) (code 10)

      • •

        incorrect determination regarding vocational factors (code 20)

      • •

        incorrect determination regarding onset relative to Title II eligibility period (code 23)

      • •

        incorrect determination regarding collateral estoppel (code 26)

      • •

        unresolved work activity that could affect the determination (code 30)

      • •

        insufficient vocational documentation to determine the claimant’s age (code 51)

      • •

        insufficient vocational documentation to determine the claimant’s education (code 52)

      • •

        insufficient vocational documentation to determine the claimant’s work history (code 53)

      • •

        failure to obtain a prior folder or copy of an administrative law judge or appeals council ruling when required by an acquiescence ruling (code 60)

      • •

        whereabouts unknown procedures not compliant with SSA policy (code 65)

      • •

        failure or refusal to cooperate procedures not compliant with SSA policy (code 66)

    2. 2. 

      Cases with group II onset deficiencies such as:

      • •

        documented period of SGA after proposed onset (code 71)

      • •

        failure to reopen a prior determination when onset falls within a previously adjudicated period and there is no medical issue to address (code 71)

      • •

        clear-cut onset date errors involving traumatic onset (code 71)

      • •

        incorrect onset decision based on vocational factors where the medical assessment is correct (e.g. borderline age (code 71))

      • •

        incorrect cessation date (CDR involving failure to cooperate or whereabouts unknown)(code 73)

      • •

        unresolved work activity that could affect onset (with no unresolved medical issue) (code 85)

        See QR 04440.950 - Exhibit of Group I and Group II Deficiency Codes in Quality Review (QR) Case Processing System for additional deficiency code information.

    3. 3. 

      Cases with technical corrective actions (TCA) such as:

      • •

        12-month medical evidence of record

      • •

        diary entry

      • •

        notice

      • •

        collateral estoppel documentation

        See GN 04440.230 - Introduction to Technical Corrective Actions (TCAs) for more information.

C. Preparing the medical referral(s) for review by an MC or PC

Once the reviewer has determined a case requires review by an MC or PC, the reviewer will submit a medical referral(s) through the case processing system. The referral should:

  • •

    identify medical issues in the case that require medical advice or clarification,

  • •

    state specific questions or frame issues for the MC or PC to review and address, and

  • •

    include information about technical issues or work issues only as they relate to the medical aspects of the case.

D. Medical review by an MC or PC

A medical review includes assessing impairment severity, the RFC, and related medical issues. The MC or PC reviews the adjudicating component's medical assessment and may independently arrive at a different assessment of impairment severity or RFC than the adjudicating component. It is NOT a “de novo” review. If the adjudicating component’s assessment complies with SSA disability program policy, and the evidence in file fully supports and documents the assessment, the MC or PC must not substitute their judgment.

As part of their medical and response, the MC or PC should:

  • •

    respond to the medical referral completed by the quality reviewer requesting MC or PC review, medical advice, or clarification of a medical issue and offer an explanation or guidance as to the course of action recommended. The advice or recommendation should be more detailed when it is not consistent with the reviewer’s guidance or possible expectations,

  • •

    provide an opinion on probability of reversal (POR) determinations, as needed. MCs and PCs must limit their opinions to the potential effect of missing documentation on impairment severity or RFC only,

  • •

    complete appropriate forms to respond to the medical referral,

  • •

    code results of a medical review in the case processing system.

The documentation in the file must fully explain the discrepancy or disagreement with the adjudicating component. MCs and PCs may prepare a SSA-3023-F3 (Medical Consultant's Review of Psychiatric Review Technique Form), SSA-392 (Medical Consultant's Review of Physical Residual Functional Capacity Assessment), or SSA-392-SUP (Medical Consultant's Review of Mental Residual Functional Capacity Assessment), to express findings of agreement or disagreement with an adjudicating component’s proposed PRT, RFC, or MRFC assessment(s).

MCs and PCs generally prepare a SSA-416 to provide medical comments if a determination should have been made on a medical-only basis (i.e., non-severe impairment(s) or impairment(s) meets/equals a listing) or the case is insufficient to establish a severe medically determinable impairment.

NOTE: For a discussion of “de novo” review and substitution of judgment, see QR 04440.003 - Explanation of Quality Review Terms and QR 04440.118 - Substitution of Judgment (SOJ) in the Quality Review Process.

E. Reviewer actions after MC or PC review

Once the MC or PC completes the medical review, the reviewer is responsible for:

  • •

    reviewing all medical responses and requesting clarification or additional information, when necessary,

  • •

    ensuring the responses adequately address all medical issues identified and the findings by the MC or PC comply with SSA regulations, rulings, POMS, and the documented facts of the case, i.e., the quality review standard (QR 04440.003G., Explanation of Quality Review Terms),

  • •

    confirming the MC or PC adequately explained their findings and prepared any necessary medical assessment forms,

  • •

    leaving all original forms completed by the adjudicating component (i.e. PRT, RFC) in the file, as part of the audit trail, even when the review component assumes jurisdiction of a case,

  • •

    ensuring that MC or PC coding in the case processing system accurately reflects the findings by the MC or PC,

  • •

    uploading all of the final forms completed by the MC or PC into eView,

  • •

    resolving discrepancies between MC or PC review findings by explaining the basis for supporting one opinion over another, and

  • •

    confirming MC or PC signatures on the determination forms are correct when assuming jurisdiction.

QR 04440.150 Processing Correct Or Corrected Disability Cases

 

A. Definition of correct or corrected cases

Correct or corrected cases are:

  • •

    Cases with no deficiencies or no technical corrective actions (TCAs)

  • •

    Cases with deficiencies or TCAs corrected by the review component

  • •

    Cases with TCAs adjudicated by the review component after assuming jurisdiction

  • •

    Cases with deficiencies or TCAs corrected by the adjudicating component (i.e. return workload units)

B. B. Procedure for processing correct or corrected disability cases

1. Processing initial or reconsideration cases

For initial and reconsideration cases, the review component will:

  • •

    Input review results, including results of deficiency returns, into the QR case processing system.

  • •

    Include any pertinent alerts or messages in the certified electronic folder (CEF) to notify the FO of necessary actions, if applicable.

  • •

    Revise the SSA-831-U3 (Disability Determination and Transmittal), if applicable.

  • •

    Upload the revised SSA-831-U3 (Disability Determination and Transmittal), if applicable.

  • •

    Effectuate the determination, if applicable.

  • •

    Date and release the notice to the appropriate claimant or appointed representative, if applicable.

NOTE: Do not effectuate reopenings. The review component must add any applicable alert or message in the CEF notifying the FO of changes in onset or filing date and the need to effectuate the determination.

2. Processing continuing disability review (CDR) cases

For CDR cases, the review component will:

  • •

    Input review results, including results of deficiency returns, into the QR case processing system.

  • •

    Include any pertinent alerts or messages in the CEF to notify the FO of necessary actions, if applicable.

  • •

    Revise the SSA-832-C3/U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal), or SSA-833-C3/U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal), if applicable.

  • •

    Upload the revised SSA-832-C3/U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal), or SSA-833-C3/U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal), if applicable.

  • •

    The review component should effectuate Title II cessations with the exception of potential 301 cases, recon CDRs, expedited reinstatements and Title XVI cessations.

  • •

    For the Title II exceptions and Title XVI cessations, add an alert or message in the CEF to inform the FO that the determination is a cessation and effectuation is necessary.

  • •

    For CDRs involving participation in vocational rehabilitation or similar program (301 involvement), the review component is responsible for deleting the Potential Section 301 certified electronic folder (CEF) flag, if necessary. For DDS procedures for cases involving vocational rehabilitation or similar program, see DI 14510.010. For adding or removing CEF flags, refer to the instructions in DI 81010.080.

  • •

    Date and release the notice to the appropriate claimant or appointed representative, if applicable.

  • •

    Route the folder to the appropriate component per instructions in DI 81020.250B.

NOTE: The Office of Disability Operations or the Program Service Center will release the notice for Title II work activity medical continuances in work incentive cases and reconsideration reversal notices.

QR 04440.201 Deficiency Citation and Support

 

A. Deficiencies

A deficiency is a specified occurrence of noncompliance with Social Security Administration (SSA) policies and procedures in a disability determination. Quality Review (QR) categorizes deficiencies as either group I or group II, according to their impact, or potential impact, on the disability determination.

B. Categories of group I and group II deficiencies

QR categorizes group I and group II deficiencies as decisional or documentation.

  • •

    Group I and group II deficiencies are categorized as decisional when a case is fully documented in accordance with SSA policy and procedures, but the adjudicating component made an incorrect determination to allow, deny, cease, continue, or establish an incorrect period of disability.

  • •

    Group I and group II deficiencies are categorized as documentation when the case requires additional medical or vocational development of evidence to make the correct determination or to determine the correct onset, ending, or cessation date.

C. Deficiency Citation

After completing a thorough review of the entire file(s), the review component will determine if the documentation is policy compliant and supports the adjudicating component’s disability determination. This includes ensuring the file contains reports of the individual’s medical history, physical and mental examinations, laboratory studies, any prescribed therapy, and any responses to therapy needed to establish one or more medically determinable impairments, assess severity of the impairment(s), and determine the duration of the impairment(s).

The review component will cite a deficiency if the evidence:

  • •

    is programmatically insufficient, including establishing the correct onset, ending, and/or cessation date,

  • •

    does not support the determination, including establishing the correct onset, ending, and/or cessation date, or

  • •

    contradicts the determination, including establishing the correct onset, ending, and/or cessation date.

The review component will identify all issues in a case and may cite multiple deficiencies, if appropriate. The most significant deficiency will be listed as “Primary” in the Disability Determination Explanation (DDE). While “Other” deficiencies may be recorded in the case processing system, the evaluation of performance accuracy or deficiency rate is predicated solely on the “Primary” deficiency cited. Deficiencies not designated as “Primary” will not impact the performance accuracy or deficiency rate of the adjudicating component. The SSA-1774-U5, Request for Corrective Action, will identify and explain each item in the case that is deficient.

Complete descriptions of each type of deficiency can be found in:

NOTE: Even if a case does not contain a deficiency, it may still contain one or more technical corrective actions (TCAs).

More information on identification and correction of TCAs can be found in:

• QR 04440.230 Introduction to Technical Corrective Actions (TCAs)

• QR 04440.231 Substantive Technical Corrective Actions (TCAs)

• QR 04440.232 Non-substantive Technical Corrective Actions (TCAs)

D. Deficiency support

When explaining the deficient element(s) in a case, the review component must support the deficiency citation with specific reference to:

  • •

    evidence in file,

  • •

    programmatically required evidence, (DI 22505.001 Medical and Nonmedical Evidence), and

  • •

    specific, relevant policy to include:

    • –

      Program Operations Manual System (POMS)

    • –

      Emergency Messages

    • –

      Administrative Messages

    • –

      Regional POMS supplements (ONLY for returns to adjudicating components in that particular region)

NOTE: The review component must not use the Office of Disability Policy memoranda, PolicyNet Questions & Answers, DDS Administrators’ Letters, Request for Program Consultation resolution responses, or other similar written guidelines, to justify or explain a deficiency.

QR 04440.202 Group I Decisional Deficiencies

 

A. Definitions of group I decisional deficiencies

A group I decisional deficiency is a substantive deficiency that affects the determination to allow or deny, or to continue or cease, disability benefits. The review component will cite a group I decisional deficiency based on the following issues:

1. Substantial gainful activity (SGA) (category 10)

This category is restricted to claims that require a medical determination for statutory blindness only, and the review indicates all of the following:

  • •

    Statutory blindness is not supported;

  • •

    The adjudicating component issued a favorable determination for reasons other than statutory blindness;

  • •

    The FO determined the claimant is currently performing non-blind SGA; and

  • •

    The adjudicating component should have denied the claim for non-blind SGA, in accordance with DI 26001.015A.2. and DI 26001.015D.2.

2. Impairment severity (category 11)

The adjudicating component based the determination on medical considerations alone (i.e., the impairment is not severe, or the impairment meets, medically equals, or does/does not functionally equal the listings). However, the evidence does not support the adjudicating component’s determination and an opposite determination is appropriate.

3. Duration (category 12)

The adjudicating component based the determination on the severity of the disabling impairment that did not meet policy requirements for 12-month duration.

4. Medical improvement (MI), including whether MI affects the ability to work (category 13)

The adjudicating component incorrectly determined MI or MI related to the ability to work, in a Continuing Disability Review (CDR).

5. MI exception regarding whether the individual has benefited from advances in medical or vocational therapy or technology (category 14)

The adjudicating component applied, or should have applied, the MI exception in a CDR regarding significant MI due to medical or vocational therapy or technology.

6. MI exception regarding successful vocational therapy (category 15)

The adjudicating component applied, or should have applied, the MI exception in a CDR regarding the individual’s successful completion of vocational therapy.

7. MI exception regarding new or improved diagnostic techniques or evaluation shows the individual's impairment(s) is not as disabling as it was at the time of the most recent prior favorable medical determination (category 16)

The adjudicating component applied, or should have applied, the MI exception in a CDR regarding new or improved diagnostic techniques that demonstrate an individual’s impairment(s) is not as disabling, as it was at the time of the most recent prior favorable medical determination.

8. MI exception regarding a prior determination made in error (category 17)

The adjudicating component applied, or should have applied, the MI exception in a CDR regarding a prior determination made in error, due to:

  • •

    error on the face of the record,

  • •

    missing required and material evidence , or

  • •

    new evidence related to the prior determination or decision.

9. MI exception regarding a prior determination based on fraudulent circumstances (category 18)

The adjudicating component applied, or should have applied, the MI exception in a CDR regarding a prior determination made in error based on documentation of fraud and similar fault.

10. Residual functional capacity (RFC) (category 19)

The adjudicating component based the determination on an RFC assessment. However, the evidence does not support the adjudicating component’s RFC and an opposite determination is appropriate.

11. Evaluation of vocational factors (category 20)

The adjudicating component determined, or should have determined, disability based on one or more of the following vocational factors:

  • •

    Age

  • •

    Education (including illiteracy)

  • •

    Transferability of skills

  • •

    Ability to perform past relevant work (PRW)

  • •

    Ability to perform other work

12. Failure to follow prescribed treatment (FTFPT) (category 21)

The adjudicating component:

  • •

    allowed or continued disability for a claimant who should have been denied or ceased because the individual failed, without good cause, to follow prescribed treatment, or

  • •

    denied or ceased disability for a claimant who should have been allowed or continued because the individual had good cause for FTFPT.

13. Drug addiction and alcoholism (DAA) materiality (category 22)

The adjudicating component:

  • •

    allowed or continued disability despite evidence that DAA is material to the determination, or

  • •

    denied or ceased disability on the basis that DAA is material, despite evidence that DAA is not material to the determination.

14. Onset of disability (category 23)

The adjudicating component allowed a title II disability claim despite:

  • •

    an established onset date (EOD) after the date last insured (DLI) for a Title II disabled worker, after the end of the prescribed period for a disabled widow(er), or after the attainment of age 22 for a childhood disability claim,

  • •

    the field office (FO) documenting the certified electronic folder (CEF) with the correct DLI, prescribed period, or childhood disability claimant's date of birth, and

  • •

    evidence indicating an earlier onset date is not supported.

15. Adoption of a prior administrative law judge (ALJ) or Appeals Council (AC) finding under an acquiescence ruling (AR) (category 25)

The adjudicating component erroneously adopted, or should have adopted, a prior ALJ or AC disability decision or specific finding (e.g., impairment severity, RFC, demands of PRW) based on an AR.

16. Collateral estoppel (category 26)

The adjudicating component:

  • •

    incorrectly adopted a prior final determination and disability cannot be established based on the current evidence in file, or

  • •

    incorrectly denied a claim when adoption of a prior favorable determination or decision was warranted.

B. Correcting group I decisional deficiencies

The review component returns all cases with group I decisional deficiencies to the adjudicating component for correction.

The review component will:

  • •

    annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the CEF, as “Do Not Process” or “Do Not Release”, as applicable,

  • •

    code the deficiency in the case processing system,

  • •

    notify the adjudicating component, via an SSA-1774-U5 Request For Corrective Action, to explain why the determination is not policy compliant and request the adjudicating component to change the determination,

  • •

    route the case to the adjudicating component for correction, as a controlled return, and

  • •

    follow-up with the adjudicating component in 30 days if the corrected determination has not been returned to the review component.

NOTE: All of the adjudicating component’s original determination and medical assessment forms, as well as notices, must remain in the CEF as part of the audit trail.

QR 04440.203 Group I Documentation Deficiencies

 

A. Definitions of group I documentation deficiencies

A group I documentation deficiency is a substantive deficiency in which the medical, vocational, functional, or other relevant evidence, is insufficient to make a determination about the claimant’s disability, such that there is potential for reversing the determination to allow or deny, or to continue or cease, disability benefits. The review component will cite a group I documentation deficiency based on the following issues:

1. Work Activity (category 30)

Category 30 applies when:

  • •

    medical evidence supports an allowance at Step 3 or Step 5,

  • •

    the file contains evidence of work activity,

  • •

    the evidence is insufficient to establish whether the work activity is ongoing SGA or "clearly not SGA", and

  • •

    a potential SGA denial applies at Step 1.

2. Medical evaluation involving vocational documentation (category 31)

The adjudicating component made an incorrect assessment of impairment severity or residual functional capacity (RFC), which makes additional vocational documentation necessary to determine disability.

3. Collateral estoppel (CE) (category 36)

The adjudicating component had insufficient documentation to determine whether adoption applied, or incorrectly adopted a prior favorable disability determination, which makes additional medical or vocational documentation necessary to determine disability on the current claim.

4. Insufficient medical documentation to determine impairment severity (category 41)

The adjudicating component based the determination on medical considerations alone (i.e., the impairment is not severe or the impairment meets, medically equals, or functionally equals the listings) without sufficient evidence to support the determination.

NOTE: The review component should not use this code if the adjudicating component’s determination is based on an RFC assessment.

5. Insufficient medical documentation to determine duration (category 42)

The adjudicating component had insufficient medical evidence to document the severity of the disabling impairment to meet policy requirements for 12-month duration.

6. Medical improvement (MI), including whether MI affects the ability to work (category 43)

The adjudicating component had insufficient medical documentation to determine whether or not MI has occurred or, whether MI is related to the ability to work in a continuing disability review (CDR).

7. RFC (category 44)

The adjudicating component based the determination on an RFC assessment without sufficient evidence to support the assessment.

NOTE: The review component should not use this code if the adjudicating component’s determination is based on medical considerations alone (i.e., the impairment is not severe, or the impairment meets, medically equals, or functionally equals the listings).

8. Failure to follow prescribed treatment (FTFPT) (category 45)

The adjudicating component had insufficient evidence to determine whether consideration of FTFPT policy was necessary prior to assessing impairment severity.

9. Drug addiction and alcoholism (DAA) materiality (category 46)

The adjudicating component had insufficient evidence to:

  • •

    determine whether DAA is material in the case, or

  • •

    determine the severity of the non-DAA impairments when DAA is material.

10. Onset of disability relative to a title II eligibility period (category 47)

The adjudicating component had insufficient evidence to determine whether onset can, or cannot, be correctly established, in a Title II disability claim, relative to the date first insured, date last insured, end of the prescribed period, or before the attainment of age 22.

11. MI exception regarding new or improved diagnostic or evaluative techniques (category 48)

The adjudicating component had insufficient evidence to determine whether new or improved diagnostic or evaluative techniques showed the individual’s impairment(s) is, or is not, as severe as previously determined in the most recent favorable medical determination, in a CDR.

12. MI exception regarding whether the individual has benefited from advances in medical or vocational therapy or technology (category 49)

The adjudicating component had insufficient evidence to determine whether the MI exception, regarding significant MI in a CDR due to medical or vocational therapy, or technology, applies.

13. Age (category 51)

The adjudicating component had insufficient evidence to determine the claimant’s age, when it is material to the determination.

14. Education or illiteracy (category 52)

The adjudicating component had insufficient evidence to determine the claimant’s education or illiteracy, when it is material to the determination.

15. Work history (category 53)

The adjudicating component had insufficient work history evidence to determine:

  • •

    relevance of past work,

  • •

    the demands of past relevant work, including physical, mental, and environmental demands, or

  • •

    transferable skills.

16. MI exception regarding advances in medical or vocational therapy or technology (category 54)

The adjudicating component obtains new medical evidence that results in a new RFC, but no MI. However, the vocational evidence is insufficient to determine whether the MI exception in a CDR regarding significant MI due to medical or vocational therapy, or technology applies.

17. MI exception regarding successful vocational therapy (category 55)

The adjudicating component had insufficient evidence to determine whether vocational therapy (related to the individual’s ability to work) improved the individual’s ability to meet the vocational requirements of more occupations, since the time of the most recent prior favorable medical determination, in a CDR.

18. Failure to obtain a prior folder or copy of the ALJ/AC ruling under an acquiescence ruling (category 60)

The adjudicating component did not obtain the prior folder or a copy of the ALJ or AC decision as required by the AR. Therefore, the evidence is insufficient to make a determination.

19. The prior determination was in error (category 61)

The prior determination was potentially incorrect, indicating a group I or II exception, but the adjudicating component did not follow policy regarding application of the exception, in a CDR.

20. Failure to follow prescribed treatment (FTFPT) (category 62)

The adjudicating component had insufficient documentation to allow or deny the claim, or continue or cease benefits, when evidence implied FTFPT was central to the assessment of impairment severity.

21. Whereabouts unknown (WU) (category 65)

The adjudicating component had insufficient documentation to deny the claim or cease benefits based on WU.

22. Failure to cooperate (FTC) (category 66)

The adjudicating component had insufficient documentation to deny the claim or cease benefits based on FTC.

B. Correcting group I documentation deficiencies

The review component returns all cases with group I documentation deficiencies to the adjudicating component for correction except for work activity category 30 deficiencies, which may require return to the field office (FO) or the adjudicating component.

1. Case returned to the adjudicating component for corrective action

For group I documentation deficiencies returned to the adjudicating component for correction, the review component will:

  1. a. 

    annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the CEF as “Do Not Process” or “Do Not Release”, as applicable,

  2. b. 

    code the deficiency in the case processing system,

  3. c. 

    notify the adjudicating component, via an SSA-1774-U5, Request For Corrective Action, to explain why the determination is not policy compliant and request the adjudicating component to obtain additional documentation,

  4. d. 

    route the case to the adjudicating component for correction as a controlled return, and

  5. e. 

    follow-up with the adjudicating component in 60 days if the case has not been returned to the review component.

NOTE: All of the adjudicating component’s original determination and medical assessment forms, as well as notices, must remain in the CEF as part of the audit trail.

2. Case returned to the FO for a group I work activity documentation deficiency (category 30)

For group I documentation deficiencies based on work activity, the review component will:

  1. a. 

    annotate all of the adjudicating component’s original determination and medical assessment forms, as well as notices, in the CEF as “Do Not Process” or “Do Not Release”, as applicable,

  2. b. 

    code the deficiency in the case processing system,

  3. c. 

    notify the FO, via an SSA-5524-U3, Request for Assistance, to explain that SGA development is needed,

  4. d. 

    notify the adjudicating component, via an SSA-1774-U5, Request For Corrective Action, to explain why the determination is not policy compliant and that the case will be routed to the FO for SGA development, and

  5. e. 

    route the case to the FO.

NOTE: All of the adjudicating component’s original determination and medical assessment forms, as well as notices, must remain in the case record as part of the audit trail.

C. Review component action after the FO documents the CEF with completed development

The review component will take action based on the results of FO work activity development and SGA determination.

1. FO determines SGA denial is applicable

After the FO resolves the work activity issue and determines an SGA denial or cessation is appropriate:

  • •

    do not effectuate the denial or cessation,

  • •

    code the case processing system for clearance, and

  • •

    route the case to the FO.

2. 2. FO determines SGA denial is not applicable

After the FO resolves the work activity issue and determines an SGA denial is not appropriate:

  • •

    code the case processing system as appropriate for clearance,

  • •

    remove or add "Do Not Process" and "Do Not Release" annotations, as applicable to the adjudicating component's original determination(s), medical assessment form(s), and notice(s),

  • •

    when necessary, correct the onset or ending date on the SSA-831-C3/U3,

  • •

    prepare and release required personalized notices, and

  • •

    route the case to the FO for effectuation.

NOTE: All of the adjudicating component’s original determination and medical assessment forms, as well as notices, must remain in the CEF as part of the audit trail.

3. FO documentation raises additional Issues- adjudicating component or FO action required

If the FO determines SGA denial is not applicable, but FO documentation raises additional issues that require adjudicating component action, initiate a subsequent return to the adjudicating component per QR 04440.205B.2.

If the FO documentation does not fully resolve SGA issues or other technical factors needed to adjudicate the claim:

  • •

    prepare a subsequent request for FO assistance via SSA-5524,

  • •

    specify the issues that need resolution or clarification, and

  • •

    control the return to the FO.

QR 04440.204 Group II Deficiencies

 

A. Definitions of group II deficiencies

There are two types of group II deficiencies, decisional and documentation. A group II decisional deficiency is a substantive deficiency in which the evidence supports a different onset, ending, or cessation date for a disability determination that is material i.e., the different date has the potential to affect the month of entitlement (MOE), the primary insurance amount (PIA), or the earnings freeze. A group II documentation deficiency is a substantive deficiency in which the evidence is insufficient and obtaining additional evidence has the potential to change the onset, ending, or cessation date for a disability determination.

1. Group II decisional deficiencies

The review component will cite a group II decisional deficiency based on the following issues:

a. Onset date (category 71 )

The adjudicating component allows a disability claim, but evidence supports a different onset date. In potential reopening situations, cite this deficiency when the adjudicating component:

  • •

    should have reopened, but did not (even when the established onset date (EOD) is correct),

  • •

    should not have reopened, but did (even when EOD is correct), or

  • •

    correctly reopened, but established an incorrect onset date that is material.

b. Ending date (category 72)

The adjudicating component allows a disability claim:

  • •

    for a closed period, but evidence supports a different ending date,

  • •

    for a closed period, but evidence is sufficient to show disability did not end, or

  • •

    for an open period, but evidence is sufficient to show disability ended.

c. Cessation date (category 73)

The adjudicating component ceases an individual’s disability benefits, but evidence supports a different cessation date.

2. 2. Group II documentation deficiencies

The review component will cite a group II documentation deficiency based on the following issues:

a. Onset date (category 81)

The adjudicating component allows a disability claim, but evidence is insufficient to support the onset date. This includes situations where the adjudicating component’s EOD falls within a previously adjudicated period, and there is insufficient evidence to determine whether the prior denial determination can be reopened.

The review component should not cite a Group II onset date documentation deficiency when the field office (FO) did not inform the adjudicating component of a prior determination, and there was no indication of a prior determination in the certified electronic folder (CEF).

b. Ending date (category 82)

The adjudicating component allows a disability claim for a closed period, but evidence is insufficient to support the ending date.

c. Cessation date (category 83)

The adjudicating component allows a disability claim, but evidence is insufficient to determine the correct cessation date.

d. Unresolved work activity that has potential to affect the period of disability (category 85)

The adjudicating component allows a disability claim, but evidence is insufficient to determine either the correct onset or ending date because of unresolved work activity.

NOTE:

When sufficient documentation exists to support a different established onset date (EOD) or if there is insufficient evidence to support the EOD, the reviewer's deficiency is based on the potential impact of the adjudicator not following policy. As explained in DI 25501.300, the EOD impacts the PIA, MOE, and the disability freeze.

B. Correcting group II deficiencies

The review component handles group II deficiencies differently, depending on the specific deficiency involved and the circumstances of the case, which may include:

  • •

    returning the case to the adjudicating component for corrective action,

  • •

    correcting the onset or ending date and processing the case, or

  • •

    sending an electronic assistance request (AR) for work activity development to the Field Office (FO).

NOTE : All of the adjudicating component's original determination and medical assessment forms, as well as notices, must remain in the CEF as part of the audit trail.

1. Case returned to the adjudicating component for corrective action - category 73, 81, 82, and 83 deficiencies

The review component returns group II documentation deficiencies involving onset (category 81), ending date (category 82), and all cessation deficiencies (categories 73 and 83) to the adjudicating component for corrective action. In these cases, the review component will:

a. code the deficiency in the case processing system,

b. complete a Request for Corrective Action per QR 04440.008B.7,

c. route the case to the adjudicating component for correction as a controlled return, and

d. follow-up with the adjudicating component in 60 days if the corrected determination has not been returned to the review component.

NOTE: If the cessation date on the SSA-832 (Cessation or Continuance of Disability or Blindness Determination and Transmittal — Title XVI) or SSA-833 (Cessation or Continuance of Disability or Blindness Determination and Transmittal –Title II) is incorrect solely due to the passage of time (i.e., the adjudicating component prepared the determination in one month and the review component conducted its review in the following month), correction should be made to the cessation date entry on the determination form and to the notice(s) without citing a deficiency. These procedures do not apply to determinations based on failure to cooperate (FTC).

2. Case corrected in the review component - category 71 and 72 deficiencies

Group II onset (category 71) and ending date (category 72) decisional deficiencies are corrected by the review component. In these cases, the review component will:

a. annotate all original determination documents, medical assessment forms, and notices completed by the adjudicating component in the CEF with "Do Not Process" or "Do Not Release", as applicable,

b. code the deficiency in the case processing system,

c. complete the Request for Corrective Action per QR 04440.008B.7,

d. correct the onset or ending date,

e. prepare and release any necessary personalized notices, and

f. route the case to the FO for effectuation.

EXCEPTION: If the case has another deficiency or technical corrective action requiring correction by the adjudicating component, or changing the ending date results in an adverse reopening of either an initial or a reconsideration case, the review component will follow the instructions in subsection B.1, to return the case to the adjudicating component for correction.

3. Correcting group II work activity documentation deficiencies - category 85

A group II deficiency based on unresolved work activity (category 85) has potential to affect the period of disability. In these cases, the review component will:

  1. a. 

    annotate all original determination documents, medical assessment forms, and notices completed by the adjudicating component in the CEF with "Do Not Process" or "Do Not Release", as applicable,

  2. b. 

    code the deficiency in the case processing system, prepare a Request for Corrective Action per QR 04440.008B7, and notify the adjudicating component of case routing to the FO for work activity development,

  3. c. 

    prepare a Request for FO Assistance outlining the specific information needed to resolve outstanding work activity issues, and

  4. d. 

    route the case to the FO.

C. Review component action after the FO responds to work activity development AR

The review component will take action based on the results of FO work activity development and substantial gainful activity (SGA) determination.

1. 1. FO resolved work activity issue - corrective action is not required

If the FO submits documentation of SGA development and a corresponding determination indicating that the onset date remains the same, the review component will:

  1. a. 

    remove the "Do Not Process" annotations from the determination forms in the CEF, as applicable,

  2. b. 

    prepare and release any necessary personalized notices, and

  3. c. 

    route the case to the FO for effectuation.

2. FO resolved work activity issue - corrective action is required

If the FO submits documentation of SGA development along with a determination necessitating a correction to the onset date, the review component will:

  1. a. 

    remove annotations of "Do Not Process" from determination forms, as applicable,

  2. b. 

    code the deficiency in the case processing system, as appropriate,

  3. c. 

    correct the onset or ending date on the SSA-831,

  4. d. 

    prepare and release any necessary personalized notices, and

  5. e. 

    route the case to the FO for effectuation.

3. FO documentation raises additional issues - adjudicating component action is required

If FO documentation raises additional issues requiring adjudicating component corrective action, the review component will initiate a subsequent return to the adjudicating component per QR 04440.205B.

4. FO documentation raises additional issues - FO action is required

If FO documentation does not fully resolve SGA issues or other technical factors needed to establish the onset date, the review component will:

  1. a. 

    prepare a subsequent Request for FO Assistance outlining the specific issues that require further development or resolution, and

  2. b. 

    route the case to the FO.


QR 04440 TN 16 - Federal Quality Review of Disability Det - 8/05/2025